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Pulmonary nocardiosis - Pulmonary
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Pulmonary nocardiosis - Pulmonary

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Contributors: Susan Voci MD, Sumanth Rajagopal MD, William Bonnez MD
Other Resources UpToDate PubMed

Synopsis

Nocardia species are saprophytic aerobic actinomycetes, gram-positive bacteria occurring worldwide in the soil, organic matter and water. They cause cutaneous, respiratory, and disseminated diseases. Patients with altered host defenses are particularly at risk for nocardiosis as they represent about two thirds of the reported cases. They include patients with chronic lung diseases, on chronic corticosteroids, with hematologic malignancies or AIDS, as well as organ transplant recipients.

Human infection can arise after cutaneous inoculation or by inhalation. N. brasiliensis is a well-known cause of cutaneous disease and is common in the southern United States, Central and South America, and Australia. N. asteroides is the species most commonly associated with invasive disease.

Pulmonary disease can present as pneumonia, a lung abscess, a cavitary lesion, or an empyema that can extend to the chest wall. Pulmonary infections are usually subacute and chronic, manifesting with a variety of radiologic manifestations. An acute fulminant pneumonia may occur. Pulmonary nocardiosis is frequently difficult to diagnose and diagnosis is often delayed. Symptoms include purulent cough, pleuritic chest pain, and fever. Hemoptysis occasionally occurs.

Nocardiosis can also rarely disseminate to the skin, causing non-specific lesions. Cutaneous inoculation of a superficial skin break results in a self-limited pyogenic skin infection such as impetigo, furuncles, carbuncles, cellulitis, and cutaneous abscesses. A rare lymphocutaneous form of the disease resembles sporotrichosis. Occasionally, cutaneous nocardiosis can result in a chronic, progressive, locally destructive mass lesion called "mycetoma" with formation of sinus tracts. CNS involvement is an important complication in the immunocompromised host and can present as a brain abscess. Rarely, bone, joints, heart, kidneys, and the eyes are involved. Bacteremia is very uncommon.

Codes

ICD10CM:
A43.0 – Pulmonary nocardiosis

SNOMEDCT:
2087000 – Pulmonary nocardiosis

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

Actinomyces spp. are also branched, beaded, and filamentous, but unlike Nocardia they do not stain with the modified acid-fast stain. Rhodococcus, Gordona, and Tsukamurella are actinomycetes like Nocardia and may be similar in appearance under direct examination. Actinomycosis is caused by an anaerobic actinomyces species and has a clinical picture in the lung similar to Nocardia infection.

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Updated: 11/02/2015
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Pulmonary nocardiosis - Pulmonary
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Pulmonary nocardiosis : Fever, Pleuritic chest pain, Productive cough, Dyspnea
Imaging Studies image of Pulmonary nocardiosis
Frontal chest x-ray with ill-defined cavitary opacity in the left upper lobe.
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